Should I initiate medication for this patient’s active Graves’ ophthalmopathy (exophthalmos)?

Management of Active Graves' Ophthalmopathy (Exophthalmos)

Yes, you should initiate systemic corticosteroid therapy for active, moderate-to-severe Graves' ophthalmopathy, as this is the mainstay of treatment for preventing vision loss and improving quality of life. 1, 2

Severity Assessment and Treatment Indications

Before initiating medication, you must determine disease severity and activity:

• Monitor carefully for vision-threatening complications: compressive optic neuropathy from orbital apex crowding or severe exposure keratopathy from eyelid retraction with exophthalmos 1
• Assess disease activity: Look for soft tissue congestion, eyelid retraction, restrictive extraocular myopathy, conjunctival hyperemia and edema, and eye pain 1, 3
• Refer to orbital specialist urgently if moderate-to-severe exophthalmos, significant orbital pain, or vision-threatening disease is present 1

First-Line Medical Treatment

For Moderate-to-Severe Active Disease:

High-dose systemic glucocorticoids are the primary medical treatment 2, 4:

• Intravenous pulse therapy (preferred route): IV prednisolone 7.5 mg/kg/day administered twice weekly for 6 weeks, then half-dose for 6 additional weeks 2
• Oral corticosteroids (alternative): Prednisone 1 mg/kg/day for 4 weeks followed by gradual tapering 3

The evidence shows that IV glucocorticoid therapy achieves satisfactory response in 72% of patients, with major improvement in diplopia (83.3% to 33.3%), eye pain (72.2% to 16.7%), and exophthalmos (44.4% to 11.1%) 2. Oral prednisone has also demonstrated effectiveness in reducing palpebral retraction, exophthalmometry, and conjunctival hyperemia within 1-4 weeks 3.

Adjunctive Treatments:

• Orbital radiotherapy may be combined with glucocorticoids for active disease 4
• Local measures for symptom control: preservative-free artificial tears, ointments, sunglasses, nocturnal eye taping 4

Critical Management Considerations

Thyroid Status Management:

Correction of both hyper- and hypothyroidism is crucial 4:

• Continue or initiate antithyroid drugs (methimazole) to achieve euthyroid state 3
• If radioiodine treatment is planned, administer prophylactic glucocorticoids to prevent ophthalmopathy progression, especially in smokers 4, 5
• Prevent post-radioiodine hypothyroidism by commencing T4 replacement 2 weeks after treatment 5

Monitoring Requirements:

• Assess for elevated intraocular pressure as part of binocular diplopia management 1
• Watch for glucocorticoid side effects, though these are typically mild and uncommon 2
• Coordinate care with endocrinology and ophthalmology specialists 1

When NOT to Use Corticosteroids Alone

Refer immediately for surgical evaluation if 1:

• Vision loss from compressive optic neuropathy
• Severe exposure keratopathy unresponsive to medical management
• Disease is severe but inactive (orbital decompression preferred over steroids) 4

Treatment Response Expectations

Response to glucocorticoid treatment is independent of 2:

• Underlying thyroid disease status
• Prior radioiodine treatment
• Smoking status

However, 30-50% of patients develop restrictive myopathy requiring subsequent rehabilitative surgery after disease inactivation 1, 4.

Common Pitfalls to Avoid

• Do not delay treatment in active moderate-to-severe disease—early intervention prevents irreversible damage 1
• Do not use corticosteroids as monotherapy for inactive disease—surgical decompression is preferred 4
• Do not administer radioiodine without glucocorticoid prophylaxis in patients with preexisting ophthalmopathy, particularly smokers 4, 5
• Do not neglect smoking cessation counseling—smoking increases risk and severity of disease 1